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21 Cards in this Set
- Front
- Back
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General
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Usual state of health
Fevers Chills Night Sweats Weight Changes Fatigue (weakness) |
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Skin
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Rashes
Itching Hives Changes in Moles Lumps/Bumps Changes in Hair Texture Changes in Nail Appearance |
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Head
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Dizziness
Headaches Fainting Hx of Head Injury (PMH) |
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Eyes
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Blurry vision
Recent changes in vision Double vision (diplopia) Eye pain Redness Discharge Excessive tearing/dryness Eye injuries (PMH) Spots before eyes (floaters) Night vision problems |
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Ears
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Difficulty hearing
Discharge Ear pain Ringing in ears (tinnitus) |
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Nose
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Nosebleeds (epistaxis)
Pain Discharge Frequent colds Sinus pain Hay Fever (PMH) |
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Mouth/Throat
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Problems with teeth or pain
Most recent dental visit Problems with gums Bleeding gums Chronic bad breath (halitosis) Hoarseness or voice changes Frequent sore throats Post-nasal drip Lumps in the mouth or tongue Difficulty swallowing (dysphagia) |
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Neck
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Lumps
Pain Stiffness Thyroid problems (PMH) “Swollen Glands” |
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Chest/Lungs
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Chest (Lungs)
Cough (productive?) Coughing up blood Discomfort (pain) Shortness of breath (SOB- dyspnea) Advise here against smoking/quitting |
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Heart/CV
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Chest discomfort/pain (angina)
SOB (dyspnea)- Exertional? When lying flat? (orthopnea- pillows) Palpations Hx of heart murmur (PMH) Ankle swelling Last EKG |
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Breasts
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Self Breast Exam (SBE)- monthly following period
Lumps Pain Discharge Tenderness |
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GI
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Appetite changes (anorexia/polyphagia)
Nausea/vomiting Constipation/diarrhea Heartburn Pain Vomiting Blood (hematemesis) Blood in stool (hematochezia) Black or tarry stools (melena) Excessive belching or gas (Flatus) Hemorrhoids (PMH/HPI) Jaundice Hx of hepatitis (PMH) Hx of liver or GB Dz (PMH) Rectal pain Change in bowel habits |
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GU
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Painful or burning urination
Frequent urination (polyuria) Urgency Urinary incontinence Blood in urine (hematuria) Bedwetting (nocturnal enuresis) Urinary retention (can’t pee) Foul urine or abnormal color |
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Male GU
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Frequent nocturnal urination (nocturia)
Difficulty starting or stopping the stream Dribbling Urgency Penile lesions Erectile dysfunction Scrotal masses Testicular pain or masses Able to enjoy sexual intercourse/loss of libido Hx of STDs (PMH) Fertility problems |
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Female GU
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Lesions on external genitalia
Vaginal itching Vaginal discharge Most recent Pap smear Painful intercourse (dysaerunia) Able to enjoy sexual intercourse/loss of libido Fertility problems Hx of STD’s Menstrual pain PRN- postmenopausal bleeding |
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Peripheral Vascular
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Pain in calves with walking
Varicose veins Hx of thrombophlebitis (blood clots) (PMH) Swelling Coolness of leg or foot Discoloration of extremity Loss of hair on legs Leg or foot ulcers |
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MSK
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Muscle or joint pain/stiffness
Joint swelling or redness Weakness in a limb Hx of gout (PMH) Back pain Deformities/Fractures Serious MSK injuries (PMH) |
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Hematologic
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Hx of anemia (PMH)
Easy bruising Abnormal blood clotting Use Warfarin (Coumadin) or Aspirin (ASA) (PMH) Hx of transfusions or transfusion reactions |
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Endocrine
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Heat or cold intolerance
Change in hair texture Frequent hunger Frequent thirst Change in hat, glove or shoe size in adult |
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Neurologic
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Headaches
Fainting Dizziness Weakness in a limb Numbness/tingling Burning pain Tremors Monocular visual loss (amaurosis fugax) Memory loss Speech difficulties Unsteady gait Behavioral changes Loss of consciousness Disorientation Difficulty concentrating Involuntary movements Noises or whooshing in head |
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Psychiatric
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Mood changes or mood swings
Excessive nervousness or anxiety Hallucinations Paranoia Delusions Depression Suicidal Ideation Homicidal Ideation |
